Person_Well Abandonment_20230428

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WELL ABANDONMENT RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. Opper 7a.Number of wells being abandoned: 3
Well Contractor Name(or well owner personally abandptirpplw ll his/her property) For multiple injection or non-water supply wells ONLY with the same
FYl �� �,, construction/abandonment,you can submit one form.
NC 3322-A •-- L.�l v D
7b.Approximate volume of water remaining in well(s): 0 (gal.)
NC Well Contractor Certification Number
Regional Probing Services
APR 2 2023 FOR WATER SUPPLY WELLS ONLY:
lnfl.,t/r.art fir'.
Company Name ,,Unfit 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Counry,State,Variance,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
0 Agricultural 0 Municipal/Public ❑Neat Cement Grout 121 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) CI Residential Water Supply(single) ❑ Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial 0 Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite:14 Ibs/ft(560-1050 lbs/well
❑Aquifer Storage and Recovery ❑Sal inity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer RW-1 (40'), RW-2 (75'), RW-3 (75')
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 2/28/2023
5a.Well location: Filled/hydrated from bottom-up. Capped with 1'of concrete.
NCSHP Roxboro Facility 8.Certification: CfV'-"--"Facility/Owner Name Facility ID#(if applicable)
-
3434 Burlington Road, Roxboro Lawrence Opper 3/24/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Person By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 1C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.35425126 79.043376 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)f available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# RW-1, RW-2, RW-3 abandonment to the following:
Division of Water Quality,Information Processing Unit,
40-75 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: PVC well I.D.6(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
10 (approx) Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
10e. For Water Supply& Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f. Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013